Important Questions Answers Why This Matters: What is the overall Participating: $0 Individual / $0 Family

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1 CA SignatureValue Alliance Coverage Period: 01/01/ /31/2017 Summary of Benefits and Coverage: What This Plan Covers & What it Costs Coverage for: Employee/Family Plan Type: HMO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why This Matters: What is the overall Participating: $0 Individual / $0 Family See the chart starting on page 2 for your costs for services this plan deductible? covers. Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? No Yes, Participating: $1,500 Individual / $3,000 Family $5,650 Individual / $11,300 Family (Prescription Drugs) Premium, copayments for supplemental benefits, and health care this plan doesn t cover. No Yes. For a list of participating providers, see or call Yes. There may be some providers or services for which referrals are not required. Yes You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the outof-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use a participating doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your participating doctor or hospital may use a non-participating provider for some services. Plans use the term in-network, preferred, or participating to refer to providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan s permission before you see the specialist. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call for Member Services or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at Guidance/Downloads/Uniform-Glossary FINAL.pdf or call the telephone numbers above to request a copy. 1 of 8

2 Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If a non-participating provider charges more than the allowed amount, you may have to pay the difference. For example, if a non-participating hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan only covers services if rendered by participating providers. Exceptions include emergency services as described in your policy. Common Medical Event If you visit a health care provider s office or clinic Services You May Need Primary care visit to treat an injury or illness Participating $15 copay per visit Specialist visit $15 copay per visit Other practitioner office visit Preventive care / screening / immunization $15 copay per visit for Chiropractic and Acupuncture services. No Charge Non-Participating Limitations & Exceptions If you receive services in addition to office visit, additional copays or coinsurance may apply. Member is required to obtain a referral to specialist or other licensed health care practitioner, except for OB/GYN Physician services and Emergency / Urgently needed services. If you receive services in addition to office visit, additional copays or coinsurance may apply. Limited to 20 visits per Calendar year for chiropractic and acupuncture services, combined. Includes preventive health services specified in the health care reform law. If you have a test Diagnostic test (x-ray, blood work) Imaging (CT / PET scans, MRIs) No Charge None No Charge None 2 of 8

3 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at or If you have outpatient surgery Services You May Need Generic Your Lowest-Cost Option Brand Your Midrange-Cost Option Non-Formulary Your Highest-Cost Option Facility fee (example: ambulatory surgery center) Participating Retail: $5 copay Mail-Order: $10 copay Retail: $20 copay Mail-Order: $40 copay Retail: $50 copay Mail-Order: $100 copay Non-Participating No Charge None Physician / surgeon fees No Charge None Limitations & Exceptions means pharmacy for purposes of this section. Retail: Up to a 30 day supply. Mail-Order: Up to a 90 day supply. You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by OptumRx. Formulary Generic Contraceptives covered at No Charge. You may be required to use a lower-cost drug(s) prior to benefits under your prescription drug policy being available for certain prescribed drugs. See the website listed for information on drugs covered by your plan. Not all drugs are covered. Emergency room services $50 copay per visit $50 copay per visit Copay waived if admitted. If you need immediate medical attention If you have a hospital stay Emergency medical transportation No Charge No Charge None Urgent care $15 copay per visit $15 copay per visit Facility fee (example: hospital room) No Charge None Physician / surgeon fees No Charge None Copay waived if admitted. If you receive services in addition to urgent care, additional copays or coinsurance may apply. 3 of 8

4 Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Services You May Need Mental / Behavioral health outpatient services Mental / Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Participating Non-Participating $15 copay per visit None No Charge None $15 copay per visit None No Charge None Prenatal and postnatal care No Charge Delivery and all inpatient services No Charge Limitations & Exceptions Additional copays or coinsurance may apply depending on services rendered. Routine pre-natal care is covered at No Charge. Your cost in this category includes Physician Delivery Charges. Additional copays or coinsurance may apply. Your cost for inpatient services only. Delivery see above. Home health care No Charge None Rehabilitation services $15 copay per visit Coverage is limited to physical, occupational, and speech therapy. Habilitative services No coverage for Habilitative services. Skilled nursing care No Charge Limited to 100 consecutive calendar days from the first treatment per disability. Durable medical equipment No Charge None Hospice service No Charge None If your child needs dental or eye care Eye exam No Charge 1 exam every 12 months. Glasses None Dental check-up No coverage for Dental check- 4 of 8

5 Common Medical Event Services You May Need Participating Non-Participating Limitations & Exceptions ups. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Long-term care Private-duty nursing Dental care (Adult) Non-emergency care when traveling outside the U.S. Routine foot care Dental care (Child) Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Chiropractic care Infertility treatment Bariatric surgery Hearing aids Routine eye care (Adult) 5 of 8

6 Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact your human resource department or the Employee Benefits Security Administration at or or Department of Managed Health Care at or Additionally, a consumer assistance program may help you file your appeal. Contact California Department of Managed Health Care Help Center at or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa CHINESE ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 NAVAJO (Dine): Dinek'ehgo shika at ohwol ninisingo, kwiijigo holne To see examples of how this plan might cover costs for a sample medical situation, see the next page of 8

7 Coverage Examples CA SignatureValue Alliance Coverage Period: 01/01/ /31/2017 Coverage for: Employee/Family Plan Type: HMO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care also will be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $7,330 Patient pays $210 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Co-pays $10 Co-insurance $0 Limits or exclusions $200 Total $210 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,660 Patient pays $740 Sample care costs: Prescriptions $2,900 Medical Equipment & Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Co-pays $700 Co-insurance $0 Limits or exclusions $40 Total $740 7 of 8

8 Coverage Examples CA SignatureValue Alliance Coverage Period: 01/01/ /31/2017 Coverage for: Employee/Family Plan Type: HMO Questions and answers about Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied to the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from inparticipating providers. If the patient had received care from out-of-participating providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, co-payments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as co-payments, deductibles, and co-insurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call for Member Services or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at Guidance/Downloads/Uniform-Glossary FINAL.pdf or call the telephone numbers above to request a copy. 8 of 8